The most
accurate way to
estimate survival is to classify the patient according to the
RTOG classes and
then use this table or more simply go
here.

Elderly patients, in poor health,
who under go a limited resection do very poorly. Anaplastic astrocytoma patients do better
than Glioblastoma multiforme patients, and low grade glioma patients do the best of
all (go here
and here. Also
patients treated with chemotherapy combined with radiation may do better (go here.)

Note that the grade
of the glioma is critical. (see images of the
different grades here.)
(Grade 1 or 2 are called low grade glioma, grade 3 is anaplastic astrocytoma, and only
grade 4 is glioblastoma.(Low grade gliomas are
discussed elsewhere,
go here.)
Grade 3 or anaplastic astrocytoma (AA) are treated similar to grade IV or glioblastoma
(GBM)
as per NCCN. But the
prognosis for a grade III glioma is much better than for grade IV, ( in the original RTOG
trial median of 27 months versus median of 8 months.

See survival sections
here
and here and the
studies noted below. Survival for recurrent
tumors treated with further surgery here

Also note that there has been more evidence of a
survival benefit when chemotherapy (e.g. temozolomide (Temodar) or thalidomide are
added to radiation) see below and in the
chemotherapy section (where
patients with glioblastoma may have a median survival of 14 - 16
months and a 2 years survival of 26 - 31%.) A recent trial
did not show much benefit from adding cisplatin (go
here) another showed real benefit for Avastin plus Camptosar (go
here). A recent trial combined radiation with
CCNU and Temodar with good results (go here).

Elderly patients have a worse outlook but they may still benefit from
radiation and chemotherapy (go here).

Survival analysis following the addition
of temozolomide to surgery and radiotherapy in patients with glioblastoma multiforme

Curran WJ Fox Chase Cancer Center, Philadelphia, PA 19111.

We used a recursive partitioning technique to analyze
survival in 1578 patients entered in three Radiation Therapy Oncology Group malignant
glioma trials from 1974 to 1989 that used several radiation therapy (RT) regimens with and
without chemotherapy or a radiation sensitizer. Twenty-six pretreatment
characteristics and six treatment-related variables were analyzed. RESULTS: The years).
Patients younger than 50 years old were categorized by histology (astrocytomas with
anaplastic or atypical foci [AAF] versus glioblastoma multiforme [GBM]) and subsequently
by normal or abnormal mental status for AAF patients and by performance status for those
with GBM. For patients aged 50 years or older, performance status was the most important
variable, with normal or abnormal mental status creating the only significant split in the
poorer performance status group. Treatment-related variables produced a subgroup showing
significant differences only for better performance status GBM patients over age 50 (by
extent of surgery and RT dose). Median survival times
were 4.7-58.6 months for the 12 subgroups resulting from this
analysis, which ranged in size from 32 to 256 patients.

Short course radiotherapy is an appropriate option for
most malignant glioma patients.

Kleinberg L,
Int J Radiat Oncol Biol Phys 1997 Apr 1;38(1):31-6

The study group includes 219 patients treated during
1975-1993 with 51 Gy in 17 fractions. Patients were
retrospectively assigned to six prognostic groups previously identified in a recursive
partitioning analysis of the RTOG. The prognostic groups are based on age, histology,
performance status, mental status, neurologic function, resection extent, length of
symptoms, and RT dose. RESULTS: The six RTOG prognostic groupings were significantly
predictive of outcome for patients treated with this shortened regimen (log-rank, p <
0.001). The median survival for our patients by RTOG groups 1-6 were
68, 57, 22, 13, 8, and 5 months, respectively. Two-year survival results were 64, 67, 45,
8, 3, and 3%. The median and two-year survival results for each prognostic grouping
were similar to the results achieved by aggressive treatment on RTOG malignant glioma
trials for selected patients. Treatment toxicity was uncommon. CONCLUSION: This shortened
regimen is an appropriate treatment option for most malignant glioma patients (RTOG groups
4-6), resulting in similar survival as standard regimens with reduced patient effort and
cost. Although acute side effects are acceptable and the risk of brain necrosis is low, we
do not recommend this treatment to the minority of patients who have a substantial long
term survival probability (RTOG groups 1-3) because long term neurocognitive assessment is
lacking.

Cancer 1983 Sep 15;52(6):997-1007

Comparison of postoperative
radiotherapy and combined postoperative radiotherapy and chemotherapy in the
multidisciplinary management of malignant gliomas. A joint Radiation Therapy Oncology
Group and Eastern Cooperative Oncology Group study.

Chang.The four options were: (1) control radiation; 6000
rad/6-7 weeks to whole brain; (2) a higher radiation dose; Control dose plus a booster
dose of 1000 rad/1-2 weeks to the tumor; (3) control radiation dose plus BCNU (80
mg/m2/day IV X 3 and repeat BCNU every 8 weeks); (4) Control radiation dose plus
combination methyl-CCNU (125 mg/m2/day orally X 1 and repeat methyl-CCNU every 8 weeks),
and DTIC (150 mg/m2/day IV X 5 and repeat DTIC every 4 weeks). Patients
who were younger than age 40 years had an 18-month survival of 64%, patients who were age
40-60 years had an 18-month survival of 20%, and patients who were older than age 60 had
an 18-month survival of 8%. Patients with anaplastic astrocytoma had a median survival of
27 months as compared to 8 months for patients with glioblastoma. In further
evaluation of any beneficial effect of chemotherapy, it was identified that only among the
40-60-year-old groups, BCNU treated patients appeared to have
significantly increased survival than patients in the control groups. Similarly,
methyl-CCNU + DTIC was suggestively better than the control.. The higher radiation dose,
7000 rad/8-9 weeks appeared to give no significantly better survival over the control dose
option.

Mohan DS, Suh JH, Phan JL, Kupelian PA, Cohen BH, Barnett
GH

We selected elderly patients (> or = 70 years) who had
primary treatment for glioblastoma multiforme at our tertiary care institution from 1977
through 1996. The study group (n = 102) included 58 patients treated with definitive
radiation, 19 treated with palliative radiation, and 25 who received no radiation. To
compare our results with published findings, we grouped our patients according to the
applicable prognostic categories developed by the Radiation Therapy Oncology Group (RTOG):
RTOG group IV (n = 6), V (n = 70), and VI (n = 26). Patients were retrospectively assigned
to prognostic group IV, V, or VI based on age, performance status, extent of surgery,
mental status, neurologic function, and radiation dose. Treatment included surgical
resection and radiation (n = 49), biopsy alone (n = 25), and biopsy followed by radiation
(n = 28). Patients were also stratified according to whether they were optimally treated
(gross total or subtotal resection with postoperative definitive radiation) or
suboptimally treated (biopsy, biopsy + radiation, surgery alone, or surgery + palliative
radiation). Patients were considered to have a favorable prognosis (n = 39) if they were
optimally treated and had a Karnofsky Performance Status (KPS) score of at least 70.
RESULTS: The median survival for patients according to RTOG groups
IV, V, and VI was 9.2, 6.6, and 3.1 months, respectively (log-rank, p < 0.0004).
The median overall survival was 5.3 months. The definitive radiation group (n = 58) had a
median survival of 7.3 months compared to 4.5 months in the palliative radiation group (n
= 19) and 1.2 months in the biopsy-alone group (p < 0.0001). Optimally treated patients
had a median survival of 7.4 months compared to 2.4 months in those suboptimally treated
(p < 0.0001). The favorable prognosis group had an 8.4-month median survival compared
to 2.4 months in the unfavorable group (p < 0.0001). On multivariate analysis, the KPS,
RTOG group, favorable/unfavorable prognosis, and optimal treatment/suboptimal treatment
were significant predictors of survival. CONCLUSION: Elderly patients with good
performance status (> or = 70 KPS) when treated aggressively with maximal resection and
definitive radiation had longer survival than those treated with palliative radiation and
biopsy. Aggressive treatment in such patients should be considered.

Int J Radiat Oncol Biol Phys 1993 May
20;26(2):239-44

Influence of location and extent of surgical resection on
survival of patients with glioblastoma multiforme: results of three consecutive Radiation
Therapy Oncology Group (RTOG) clinical trials.

Six hundred forty-five patients with a diagnosis of
glioblastoma multiforme on central pathological review were analyzed for survival with
respect to known prognostic factors, that is, age and Karnofsky Performance Status, as
well as extent of surgery, site, and size. Surgical treatment consisted of biopsy only in
17%, partial resection in 64%, and total resection in 19%. Tumors were located in frontal
lobe in 43%, temporal lobe in 28%, and parietal lobe in 25%. Maximum tumor diameter as
determined on computed tomography or magnetic resonance imaging scans was less than 5 cm
for 38%, between 5-10 cm for 56% and greater than 10 cm for 6% of patients. The extent of
surgical therapy was the same for tumors greater than 5 or greater than 10 cm, whereas
total resection was more often performed for tumors less than 5 cm. The extent of surgery
did not appear to vary with age or site. RESULTS: Patients
undergoing total resection had a median survival of 11.3 months compared to 6.6 months for
patients with a biopsy only. A significant difference in median survival was also found
for partial resection versus biopsy only treatment (10.4 vs. 6.6 months). There was no
difference in survival for the different tumor sizes. Patients with frontal lobe tumors
survived longer than those with temporal or parietal lobe lesions (11.4 months, 9.1
months, and 9.6 months, respectively) (p = 0.01). A Cox multivariate model
confirmed a significant correlation of age, Karnofsky Performance Status, extent of
surgery, and primary site with survival. The best survival rates occurred in patients who
had at least three of the following features: < 40 years of age, high Karnofsky
Performance Status, frontal tumors, and total resection (17 months median). CONCLUSION: We
conclude that biopsy only yields inferior survival to more extensive surgery for patients
with glioblastoma multiforme treated with surgery and radiation therapy.

Int J Radiat Oncol Biol Phys 1998 Dec
1;42(5):977-80

Efficacy of radiotherapy for malignant gliomas in elderly
patients.

Service of Radiation Oncology, Institut Catala d'Oncologia,
L'Hospitalet, University of Barcelona, Spain.

We examined 85 consecutive elderly patients with a
histological diagnosis of MG. Age ranged from 65 to 81 years (median 70 years).
Glioblastoma multiforme (GBM) was diagnosed in 64 patients (75.3%). Surgical treatment
included needle biopsy in 32 patients (37.6%). Median postoperative Karnofsky Performance
Status (KPS) was 60 (range: 30-100). Median survival time for all
patients was 18.1 weeks. In multivariate analysis, RT was the only independent
prognostic variable for survival (HR: 9.1 [95% CI: 4.5-18.7]). Forty-two patients did not
start RT mostly due to low KPS (<50). The median survival of the 43 patients who
started RT was 45 weeks. In these patients, Cox multivariate analysis indicated that age
was independently associated with prolonged survival (HR: 2.85 [95% CI 1.31-6.19]). Median
survival of patients age 70 years and younger was 55 weeks compared with 34 weeks for
patients older than 70 years. CONCLUSIONS: The overall survival for elderly patients with
MG is poor. RT seems to improve survival in patients up to 70 years, but in older patients
treated with RT the survival is significantly shorter.

Cancer 1999 Nov 15;86(10):2117-23

The role of tumor resection in the treatment of
glioblastoma multiforme in adults.

BACKGROUND: The therapeutic impact of tumor resection is
poorly defined. Therefore the current study was conducted. METHODS: A retrospective,
2-institutional study was conducted (1991-1994) to compare the treatment results of
stereotactic biopsy plus radiation therapy (99 patients; tumor dose: 60 gray [Gy]) with
those of surgical resection plus radiation therapy (126 patients; tumor dose: 60 Gy).
Patients were categorized in the Radiation Therapy Oncology Group (RTOG) Classes IV (46
patients), V (157 patients), and VI (22 patients). The resection group and the biopsy
group did not differ in terms of age, pretreatment Karnofsky performance status KPS),
gender, duration of symptoms, presenting symptoms, tumor location, tumor size, and the
frequency of midline shift. Patients in the biopsy group more often were found to have
left-sided tumors (P < 0.001). Transient perioperative morbidity and mortality rates
were 1% and 1%, respectively, in the biopsy group and 5% and 1.6%, respectively, in the
resection group (P > 0.05). The median survival time was 37 weeks
for the resection group and 33 weeks for the biopsy group. The difference was not
statistically significant (P = 0.09). The most favorable pretreatment prognostic factor
was patient age < 60 years (P < 0.01). Tumor resection was highly effective in
patients with midline shift (P < 0.01). In patients without midline shift radiation
therapy alone was found to be as effective as tumor resection plus radiation therapy (P =
0.5). Patients with midline shift were more likely to have a worse KPS during the course
of primary radiation therapy (P < 0.05). CONCLUSIONS: For RTOG Classes IV-VI patients
with moderate mass effect of the tumor, radiation therapy alone is a rational treatment
strategy. Tumor resection should be performed in patients with pretreatment midline shift
whenever possible.

PURPOSE: To evaluate efficacy of short-course radiotherapy
(RT) in elderly (> or = 60 years) and frail [Karnofsky performance status (KPS) 50-70]
patients with glioblastoma multiforme (GBM).RT alone was administered with tumor dose of
45 Gy in 15 daily fractions in 15 treatment days in 3 weeks to a target volume described
as tumor visible on CT scan and a 2-cm margin. RESULTS: Forty-four patients were evaluable
for this analysis. There were 15 (34%) CR and 11 (25%) PR, making the overall response
rate of 60%. Median duration of response was 9 months (range, 2-36 months). Improvement in
pretreatment performance status was observed in 20/44 (45%) patients, 5 of which improved
their KPS for 20%. Median survival time is 9 months, and 1-4
year survival rates are 39%, 6.8%, 4.5%, and 0, respectively, while median time to tumor
progression is 8 months, and 1-4 year progression-free survival rates are 30%, 4.5%, 4.5%,
and 0, respectively. Females did significantly better than males, patients with KPS 60-70
did significantly better than those with KPS 50, patients having tumors 4-5 cm did
significantly better than those with tumors 6-8 cm as well as did those with more radical
surgery when compared to those with biopsy only. On multivariate analysis, only tumor size
and extent of surgery were found to independently influence survival. Acute toxicity was
generally assessed as mild. One of the 12 (8%) autopsied patients had RT-induced brain
necrosis. CONCLUSION: This shortened RT appears to be an effective tool in palliation of
elderly and frail patients with GBM. Further studies with more patients are needed before
testing it against more aggressive treatment approaches in this patient population.

Neurosurgery 1994 Jan;34(1):62-6; discussion 66-7

The limited value of cytoreductive surgery in elderly
patients with malignant gliomas.

Kelly PJ, Hunt C

Department of Neurosurgery, Mayo Clinic, Rochester,
Minnesota.

In this retrospective, consecutive series of 128 elderly
patients (over 65 years of age) with histologically proven Grade 4 astrocytomas, 88
patients underwent stereotactic biopsy and 40 patients underwent stereotactic volumetric
resection of the mass lesion defined by contrast enhancement on computed tomography. There
were no significant differences in age (average age in the biopsy group, 71.6 yr;
resection group, 70.15 yr) or Karnofsky Performance Scores (biopsy group, 84.33; resection
group, 83.88) between the two groups. Four of the biopsy patients and one of the resection
patients died within 30 days of surgery. The overall mean survival
was 126 days; 108 days (15.4 wk) in the patients who had biopsies and 189 days (27 wk) in
the patients who had resections. Radiation therapy was completed in 62 of the
patients who had biopsies (mean survival, 118 d or 16.9 wk) and 34 of the patients
undergoing resection (mean survival, 210 d or 30 wk) (log rank P = 0.0215; Smirnov P =
0.006). Although some prolongation of survival is noted after resection (more than after a
biopsy) in selected patients over 65 years of age, that benefit is modest.

This report evaluates the long-term survival of patients
with histologically confirmed anaplastic astrocytoma on several combined RTOG (Radiation
Therapy Oncology Group) studies. Median survival for patients treated with RT only is 3.0
years. Median survival for patients treated with RT + Chemo is 2.3
years, and for patients treated with RT + Chemo/Miso is 1.2 years. Five-year survival
rates are 35% for patients treated with RT only, 29% for patients treated with RT + Chemo,
and 24% for patients treated with RT + Chemo/Miso. Age and performance status have
been identified in previous studies as important prognostic variables and are confirmed in
this analysis. Patients treated with misonidazole had a significantly worse prognosis
after adjustment for differences in prognostic factors. Addition of chemotherapy did not
improve survival except in less favorable prognostic categories. In general, more
aggressive treatment regimens are associated with decreased survival compared to
conventional postoperative irradiation.